RIA expert Summary

Substance Abuse in Older Adults: A Hidden Problem

An elderly person you know is having balance problems and difficulty remembering things.

What’s your first thought? “Well, it’s to be expected.” “It’s just old age.”“I hope it’s not Alzheimer’s.” Would you ever think… “It could be substance abuse”?

Most Americans think alcohol and drug problems are issues that mainly affect adolescents or younger adults. However, one of the fastest growing health problems in the United States is substance abuse among adults age 65 and older.

According to recent studies by the Substance Abuse and Mental Health Services Administration (SAMHSA), alcohol and drug abuse affects as many as 17 percent of older adults. The problem is expected to grow, as the elderly population in the U.S. will increase significantly over the next 20 years with Baby Boomers reaching retirement age. Only 13 percent of Americans were over 65 at the time of the 1990 U.S. census; it is projected that group will represent 21 percent of the population by 2030. Experts predict the number of older adults who need treatment for substance abuse could double in the near future.

A difficult problem to detect in the elderly

Substance abuse in older adults is sometimes referred to as a hidden problem. It’s underidentified, underdiagnosed and undertreated by the health care system at even higher rates than in younger populations.

Alcohol and drug problems in the elderly are often missed by family, friends and health care professionals, because:

Symptoms of substance abuse such as increasing fatigue, diminished cognitive capacities and balance problems can be mistaken for dementia, depression or other problems common to older adults.

Older adults are more likely to hide their alcohol or drug use and less likely to seek professional help than other age groups.

Many older adults are isolated from family and friends who are no longer close by and involved in their day-to-day life.

Multiple medications for health conditions can mask the signs of addiction.

Health care professionals do not routinely ask about and screen for substance use problems in older adults.

Different reasons for substance abuse

Older adults with substance abuse problems can be broadly divided into two groups. The first are long-term substance users who have reached age 65. This group is projected to expand in number as the elderly population in the U.S. increases over the next 20 years.

The second are “late-onset” individuals who begin abusing substances later in life. They may turn to alcohol or drugs to cope with stresses associated with old age, such as health concerns, reduced income or loss of a spouse or loved ones. Other stressors can include sleeping problems or family conflicts. Even a positive development such as retirement can carry risks for substance abuse, as it offers individuals more leisure time in which to drink, along with fewer consequences for their behavior.

These late-onset substance users rarely use alcohol or drugs to “get high,” in contrast to sensation-seeking teenagers or young adults. Rather, they use alcohol or drugs as a means to deal with negative emotions that commonly occur in older adults, such as loneliness, isolation, boredom, fear and anxiety, or to combat the various physical pains that become more prevalent as people age.

What can be done

If an intervention is necessary to begin treatment, addiction professionals suggest that no more than one or two relatives or friends take part along with a health care provider, because having too many people involved may overwhelm or confuse an elderly person. Privacy also is important, as many older people feel more shame or stigma than younger individuals for “losing control” at their age.

As with all people with substance abuse problems, Twelve Step programs, mutual-help and support group participation should be considered. In serious cases, inpatient treatment may be necessary.

Although experts say the content of treatment programs does not need to be any different than for younger populations, the presentation should be tailored to best suit older adults. For example, accommodations may need to be made for people with hearing loss or who exhibit cognitive changes. Options can include a slower pace, speaking louder and more repetition of material.

SAMHSA recommends these guidelines to assist older adults in these programs:

Group treatment should be age-specific, supportive and nonconfrontational, with the aim of building or rebuilding self-esteem Ensure pace and content of treatment is appropriate for an older person

Offer assistance in coping with depression, loneliness and loss (e.g., death of a spouse, retirement) Focus on rebuilding the person’s social support network

Treatment should be staffed by professionals who are interested and experienced in working with older adults

Provide links to medical services, services for the aging and institutional settings for referral into and out of treatment, as well as case management

More potential for problems

As with younger adults, alcohol is the most commonly abused drug for older substance users. However, age can led to more problems with alcohol, for two reasons. First, the body does not metabolize alcohol at the same rate, so people can become intoxicated on a smaller amount than when they were younger. Second, the common use of medication in older adults can lead to dangerous drug and alcohol interactions.

What a person may have, in the past, considered “social drinking” may veer into risky territory. The National Institute on Alcohol Abuse and Alcoholism and the American Geriatrics Society define “risky drinking” for adults 65 and older as more than seven alcoholic drinks per week or more than three drinks on a single day. Experts recommend that older men have no more than two servings of alcohol, and older women have no more than one, on each occasion they drink.

The danger of negative drug interactions in older adults can occur with or without alcohol. People age 65 and up consume more prescription and over-the-counter medications than any age group in the U.S., with the average older adult taking at least two medications a day, sometimes many more. In addition to the risk of interaction, there also is the potential of developing a dependency or addiction to drugs such as painkillers (opiates) or sleep aids. Health care professionals need to keep a close eye on the type and amount of medications their older patients take.

What to look for

Substance abuse and misuse by older adults often goes unnoticed not only by friends and relatives but also by health care professionals. As the signs of substance abuse in older adults are often difficult to distinguish from other health problems in the elderly, it is important that health care professionals directly ask about drinking habits, use of illegal substances, and prescription and over-the-counter drug use.

According to SAMHSA’s Center for Substance Abuse Treatment, symptoms of substance abuse in older adults may include:

Memory trouble after having a drink or taking medication

Loss of coordination (walking unsteadily, frequent falls)

Changes in sleeping habits

Unexplained bruises

Irritability, sadness, depression

Unexplained chronic pain

Changes in eating habits

Wanting to stay alone much of the time

Failing to bathe or keep clean

Having trouble concentrating

Difficulty staying in touch with family or friends

Lack of interest in usual activities

In addition, health professionals can use a variety of validated screening tools, including the CAGE questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G).

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